Training VAE 2014 Case Studies2

8/10/2019 Training VAE 2014 Case Studies2

1/38

VAE

Questions

and

Case

Studies

Cindy

Gross,

MT,

SM

(ASCP),

CIC

IPConsultant

March14,2014

National Center for Emerging and Zoonotic Infectious Diseases

Division of Healthcare Quality Promotion


2/38

Thefollowingexamplesareforillustration

purposes

only

and

are

not

intended

to

represent

actual

clinical

scenarios.


3/38

WhenshouldIusePNEU/VAPinsteadofVAE?

A. NeveralwaysuseVAE

B.

When

surveillance

is

to

be

conducted

in

mechanically

ventilatedchildrenwhoareinpediatriclocations

C. Whensurveillanceistobeconductedforhealthcare

associated

pneumonia

that

is

not

associated

with

mechanical

ventilation

D. B and C

E. Noneoftheabove


4/38

NHSN Lower Respiratory Events in 2014

VAP protocol is in use for in-plan surveillance in

pediatric locations (pedVAP)

In-plan neonatal VAP surveillance is no longer available as of

January 2014

PNEU definitions are still available for off-plan

surveillance of VAP in adults , children, neonates ornon-ventilated PNEU in adults, children or neonates.


5/38

WhenevaluatingpatientdatatoseeiftheIVAC

definition

is

met,

I

should

focus

only

on

antibioticsthatareusedtotreatrespiratory

infectionsA.

Yes

B.

No


6/38

IVACandAntimicrobialAgents

MeetingInfectionrelatedVentilatorAssociated

Complication

(

IVAC)

definition

does

not

mean

that

the

infection

related

event

is

necessarily

respiratory

in

origin.

The

IVAC

antimicrobial

list

was

refined

by

removing

selected

antimicrobialagentsthatwouldnotbeused,orwouldbe

unlikely

to

be

used,

in

treating

a

lower

respiratory

infection

in

a

critically

ill

patient.

Stillpossiblethatanexistingagentmayhavedualpurposes

and

not

necessarily

be

treating

a

respiratory

infection.

No

need

to

discern

the

reason

for

the

administration

of

the

antimicrobial.

Prophylaxis,deescalation,changewithinaclassofantimicrobialsis

not

a

reason

for

exclusion


7/38

WhenselectingthedailyminimumPEEPand

FiO2for

each

calendar

day..

1. Throwoutthelowestvalue

2.

Choose

the

most

consistent

value

3.

Select

the

value

using

any

24

hour

time

period

4.

Choose

the

lowest

value

thathasbeenmaintained

for

at

least

1

hour


8/38

Choosethelowestsettingthathasbeen

maintained

for

at

least

1

hour

When

choosing

the

daily

minimum

PEEP

and

FiO2,use

all

settings

that

are

recorded

during

times

when

the

patient

is

receiving

support

from

an

eligible

mode

of

mechanical

ventilation

and

the

patient

is

eligible

for

VAE

surveillance

Include

settings

collected

during

weaning/mechanical

ventilationliberationtrialsaslongasthepatientisventilated

Use

conventional

mechanical

ventilation

settings

IncludeconventionalMVsettings duringtimeswhenapatientis

intermittentlyonanexcludedmodeofventilation

IncluderecordedPEEPsettingsduringtimeswhenapatientisnoton

APRVorasimilarmodeofventilation.

Use

a

calendar

day

not

some

other

capture

period

or

other

designated

24

hour

time

period


9/38

Daily

Minimum

Values

Thepatientisintubatedat2pm. PEEPandFiO2

are

set

at

the

following

values

through

the

remainder

ofthecalendarday.WhatarethedailyminimumPEEP

andFiO2 valuesforthecalendarday?

Time 2 pm 4 pm 6pm 8 pm 10 pm 12 am

PEEP

(cmH2O)

5 8 5 8 8 10

FiO2 1.0 0.60 0.40 0.50 0.55 0.60


10/38


11/38

Daily

Minimum

Values

Thepatientisintubatedat6pm. PEEPandFiO2

are

set

at

the

following

values

through

the

remainder

of

thecalendarday.WhatarethedailyminimumPEEP

andFiO2?

Time 6 pm 7 pm 8 pm 9 pm 10 pm 11 pm

PEEP

(cmH2O)10 8 5 5 8 8

FiO2 1.0 0.60 0.40 0.50 0.60 0.60


12/38

6

WhatarethedailyminimumPEEPandFiO2?

1. 5 and 0.40

2. 8 and 0.60

3. 10 and 1.0

4. 5 and 0.60

Time 6 pm 7 pm 8 pm 9 pm 10 pm 11 pm

PEEP

(cmH2O)

10 8 5 5 8 8

FiO2 1.0 0.60 0.40 0.50 0.60


13/38

PEEP

2

3

MeetingVACDefinition

What

if

the

increase

over

the

baseline

period

meets

therequirementrelativetoonebaselineday?

1. VAC2. NO VAC

MV DayDaily minimum Daily minimum

FiO2

1 10 100

7

90

5 90

4 8

50

5 8 50

6 8 50


14/38

PEEP

1

2

3

MeetingVACDefinitionWhat

if

there

is

an

increase

for

one

day

and

then

a

decrease?

1. VAC2. NO VAC

MV DayDaily minimum Daily minimum

FiO2

10 100

5 90

5 90

4

8

50

5 7 50

6 8 50


15/38

1

2

C

MeetingVACDefinition

VA

or

No

VAC?

MV DayDaily minimum

PEEP

Daily minimum

FiO2

10 100

5 90

3 5

90

4 10 50

5 8 50

6 8 50

1. Yes2. No


16/38


17/38

Report

an

IVAC

no

pathogen and

evaluate

to

see

if

the

positive

blood

culture

is

secondary

to

another

HAI

or

if

it

is

a

CLABSI

pathogen=PA

A.

ApatientinmyICUmettheIVACdefinition.OntheVAE

EventDate,therewasalsoapositivebloodculturethat

grew

Pseudomonas

aeruginosa.

The

patient

has

a

central

line.Otherthanfever,therearenoother

signs/symptomsofinfection.HowshouldIreportthis

event?

B. ReportanIVAC(pathogen=PA)

C.

Report

an

IVAC

and

secondary

BSI

(pathogen=PA)

D.

Report

a

CLABSI

(pathogen=PA)

E. ReportanIVAC(nopathogen)

F.

None

of

the

above


18/38

Secondary

BSI

can

only

be

reported

for

possible

or

probable

VAP

Organismsisolatedfromthebloodculture mustmatchanorganism

isolated

from

an

appropriate

respiratory

tract

specimen

that

was

usedtomeetthepossibleorprobableVAPdefinition

Blood

culture

must

be

collected

during

the

14

day

event

period

If

the

blood

culture

is

not

found

to

be

secondary

to

VAE

look

to

the

other

HAI

definitions

(including

PNEU

and

LRI)

or

report

as

a

CLABSI

Possible

or

probable

VAP

met

but

no

organism

match

and/or

blood

culturenotcollectedduring14dayeventperiod

VAC,

IVAC

or

No

VAE

detected


19/38


20/38


21/38

Whatspecificeventshouldbereportedforthispatient?

MV

DAY

Daily

minimum

PEEP

Daily

minimum

FiO2 Temp WBC ABX ABX

Speci-

men

Polys

/Epis Organism

1 8 100 38.0Pip /

Tazo

2 6 50 39.0Pip /

TazoSputum

Scant NF,

Many Staph.

aureus

3 5 50 37.6 4.9Pip /

Tazo

Vanco-

IV

4 6 40 38.6 5.8

5 6 70 39 5.8Vanco-

IV

6 6 70 38.8 5.4 BAL

104 cfu/ml

S. aureus

7 5 60 38.0 5.4Vanco-

IV

8 5 70

9 5 60Vanco-

IV


22/38

Whatspecificeventshouldbereportedforthis

patient?

A.

None,

the

patient

had

CAP

B.

presentonadmission

Possible

VAP

(pathogen

SA)

C.

Probable

VAP

(Pathogen

SA)

D.

VAC

only


23/38

5 50 37 6 4 9

Pip /

Tazo

Vanco

IV

6 40 38.6 5 8

6 70 39 5 8

Vanco

IV

6

70 38.8

5 4 BAL

10

4

cfu/ml

S aureus

5 60 38.0 5 4

Vanco

IV

MVDAY

Daily

minimumPEEP

Daily

minimumFiO2 Temp WBC ABX ABX

Speci-men

Polys/Epis Organism

1 8 100 38.0Pip /

Tazo

2 6 50 39.0

Pip /

Tazo Sputum

Scant NF,

Many Staph.aureus

3

4

5

6

7

8 5 70

9 5 60Vanco-

IV


24/38

CASE

1

Recap

PatientsarenotexcludedfromVAEsurveillancedueto

admittingdiagnosis, presenceofunderlyingconditionsor

development

of

complications

EligiblepathogensidentifiedduringtheVAEwindowperiod

aretobeusedtodetermineifpossibleorprobableVAP

definitions

can

be

met

even

if

the

same

or

similar

pathogen

was

identified

prior

to

the

event

detection

Daysbetweenadministrationofthesamenewantimicrobial

agent

count

as

QADs

as

long

as

there

is

a

gap

of

no

morethan1calendarday.


25/38

Case

Study

2

A

17

year

old

female

with

cystic

fibrosis

is

admitted

to

the

adult

medicalICUwhereinplanVAEsurveillancehasbeenselected

in

the

monthly

reporting

plan.

She

is

placed

on

the

ventilator

onhospitalday5.Basedonthefollowingfindingsdoyouneed

to

report

anything

to

NHSN.


26/38

CaseStudy2DoyouneedtoreportanythingtoNHSN?

MV Day PEEP minFiO2mi

nTemp min Temp max WBC min WBC max Abx Speci-men

Polys /

Epis Organism

1 6 50 None -- -- --

2 6 50 None -- -- --

3 6 50 37.0 37.9 5.4 5.4 None -- -- --

4 7.5 80 36.5 37.3 7.2 9.2 None -- -- --

5 7.5 80 36.3 38.9 7.4 8.4 None BAL25 /

10

104 cfu/ml

Pseudomonas

aeruginosa

6 7.5 75 37.2 38.5 8.5 8.8 Yes -- -- --

7 6 75 Yes -- -- --

8 6 75 Yes Blood -- Staph aureus

9 6 60 Yes -- -- --

10 8 80 Yes -- -- --

11 8 80 Yes -- -- --12 6 60 Yes -- -- --

13 6 60 Yes -- -- --

14 6 60 Yes -- -- --

15 6 60 No -- -- --

16 7.5 85 No -- -- --

17 7.5 85 No -- -- --


27/38

Case

Study

2

1.

Nothing

to

report

to

NHSN

2.

Probable

VAP

with

a

secondary

BSI

(pathogens

PA,

SA)

3. ProbableVAP(pathogenPA)

4.

Probable

VAP

(pathogen

PA)

and

perhapsasecondaryBSItoanother

HAI

site

or

CLABSI

(pathogen

SA)

5.

Probable

VAP

(pathogen

PA)

and

a

CLABSI

(pathogen

PA)


28/38

6

50

37 0 37 9 5 4 5 4 None

7 5

80

36 5 37 3 7 2 9 2 None

7 5

80

36 3

38.9

7 4 8 4 None BAL

25 /

10

10

4

cfu/ml

Pseudomonas

aeruginosa

7 5 75 37 2 38 5 8 5 8 8

Yes

MV Day PEEP minFiO2mi

n

Temp min Temp max WBC min WBC max Abx Speci-menPolys /

EpisOrganism

1 6 50 None -- -- --

2 6 50 None -- -- --

3 -- -- --

4 -- -- --

5

6 -- -- --

7 6 75 Yes -- -- --

8 6 75

)

Day

s

Yes Blood -- Staphaureus

9 6 604 Yes -- -- --

10 8 80d(1 Yes -- -- --

11 8 80rio Yes -- -- --

12 6 60Pe Yes -- -- --

13 6 60nt Yes -- -- --

14 6 60Eve

Yes -- -- --

15 6 60 No -- -- --

16 7.5 85 No -- -- --

17 7.5 85 No -- -- --


29/38


30/38

CaseStudy3

An

elderly

gentleman

is

admitted

to

the

trauma

ICU

followingamotorvehicleaccident.Hehadbeen

intubated

in

the

field

and

there

was

some

concern

of

aspiration

upon

intubation.

Given

the

following

information,

identify

all

events.

C S d 3 Id if ( ) d MV d f


31/38

CaseStudy3Identifyevent(s)andMVdayof

event(s)

MV DayPEEP

min

FiO2m

in

Temp

min

Temp

max

WBC

min

WBC

max

Abx SpecimenPolys /

EpisOrganism

1 6 30 37.1 37.6 4.3 4.3 None -- -- --

2 6 30 36.8 37.2 4.6 4.6 None -- -- --

3 6 30 37.0 37.9 5.4 5.4 None -- -- --4 8 30 36.5 37.3 7.2 9.2 None -- -- --

5 8 35 36.3 37.2 7.4 12.5 None -- -- --

6 8 50 37.2 37.9 8.5 13.0 Yes BAL25 /

10104 Enterococcus

7 6 50 37.8 37.3 -- -- Yes BC x2 -- Enterococcus

8 6 40 37.2 37.9 -- -- Yes -- -- --

9 6 40 37.5 37.9 9.7 11.7 Yes -- -- --

10 8 40 37.4 37.1 9.6 10.9 Yes -- -- --

11 8 40 37.2 37.9 9.4 9.4 Yes -- -- --

12 6 30 37.3 37.5 9.5 9.5 Yes -- -- --

13 6 30 37.2 37.8 8.2 8.2 None -- -- --

14 6 30 37.0 37.7 8.6 8.6 None -- -- --

15 6 60 37.2 37.9 9.4 12.1 Yes -- -- --

16 7 60 37.3 37.5 13.0 13..5 Yes -- -- --

17 7 85 37.2 37.8 -- --- Yes -- -- --

18 PATIENT EXPIRES ----- ----- ----- ----- -- -- --


32/38


33/38

6 30 37 2 37 8 8 2 8 2

None

6

30

37 0 37 7 8 6 8 6

None

6 60 37 2 37 9 9 4 12.1 Yes

7 60 37 3 37 5 13.0 13.5 Yes

7 85 37 2 37 8

Yes

PATIENT EXPIRES

CaseStudy3

VAC

MV

Day

15

MV DayPEEP

min

FiO2m

in

Temp

min

Temp

max

WBC

min

WBC

max

Abx SpecimenPolys /

EpisOrganism

1 6 30 37.1 37.6 4.3 4.3 None -- -- --

2 6 30 36.8 37.2 4.6 4.6 None -- -- --

3 6 30 37.0 37.9 5.4 5.4 None -- -- --4 8 30 36.5 37.3 7.2 9.2 None -- -- --

5 8 35 36.3 37.2 7.4 12.5 None BAL25 /

10104 Enterococcus

6 8 50 37.2 37.9 8.5 13.0 Yes -- -- --

7 6 50 37.8 37.3 -- -- Yes BC x2 -- Enterococcus

8 6 40 37.2 37.9 -- -- Yes -- -- --

9 6 40 37.5 37.9 9.7 11.7 Yes -- -- --

10 8 40 37.4 37.1 9.6 10.9 Yes -- -- --

11 8 40 37.2 37.9 9.4 9.4 Yes -- -- --

12 6 30 37.3 37.5 9.5 9.5 Yes -- -- --

13 -- -- --

14 -- -- --

15 -- --4 QAD --16 -- re --quireme --nt17 -- --- -- -- --

18 ----- ----- ----- ----- -- n --ot met --

C St d 3 R


34/38

CaseStudy3Recap

Event

Day

15

(first

day

of

onset

of

worsening

oxygenation)

VAE

Window

Period

is

Day

13,

14

(two

days

before),

Day

15

(eventday),Day16,17(twodaysafter)

Abnormal

WBC

documented

during

VAE

Window

Period

but

only

3

QADs

are

observed

prior

to

the

patient

expiring

Baselineperiodofstabilityisnotestablishedearlyin

mechanical

ventilation

episode

No

VAC,

No

IVAC,

No

Possible/Probable

VAP

PEEP


35/38

CaseStudy3

Focus

on

identifying

VAC

No

need

to

collect

other

parametersinadvance

Using

a

culture

driven

surveillance

approach

is

not

usefulforVAE

MV DayPEEP

min

FiO2 min

1 6 30

2 6 30

3 6 30

4 8 30

5 8 356 8 50

7 6 50

8 6 40

9 6 4010 8 40

11 8 40

12 6 30

13 6 3014 6 30

15 6 60

16 7 60

17 7 8518 PATIENT EXPIRES


36/38

Questions


37/38


38/38

THANKYOU!

[email protected]

For more information please contact Centers for Disease Control and Prevention

1600 Clifton Road NE, Atlanta, GA 30333

Telephone, 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348E-mail: [email protected] Web: www.cdc.gov

The findings and conclusions in this report are those of the authors and do not necessarily represent the official

position of the Centers for Disease Control and Prevention.

National Center for Emerging and Zoonotic Infectious Diseases

Division of Healthcare Quality Promotion
mailto:[email protected]:[email protected]:///reader/full/www.cdc.govmailto:[email protected]:[email protected]:///reader/full/www.cdc.gov

Training VAE 2014 Case Studies2

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